Download Borderline Personality Disorder-Comprehensive

Borderline Personality Disorder:
Comprehensive Management in Ordinary
Clinical Practice
Michael H Stone, MD
Professor of Clinical Psychiatry
Columbia College of Physicians & Surgeons
1
Borderline Domains
Gunderson’s BPD
Borderline Personality
Organization: Kernberg
BPD//DSM
Kohut’s Borderline Pers.
2
BPD: More a Syndrome than a True
Personality Disorder
The BPD of DSM is composed of a few personality traits (impulsivity, irritability &
anger, moodiness), several symptoms (self-damaging acts, suicidal gestures & selfmutilation, anxiety in situations ordinary people handle more easily) and cognitive
peculiarities ( enfeebled sense of identity, extreme attitudes in relation to other
people, feelings of emptiness, tendency to paranoid ideas or to dissociation.
This mixture gives BPD its syndromal character (it is not made up solely of traits).
BPD does not occur in the absence of other identifiable conditions. Usually there
will be accompanying symptom disorders (from “Axis-I”) and at least the traits of
other personality disorders (from “Axis –II”). These other traits may suffice to
meet criteria for one of more such disorders,or may fall short of full criteria (in
which case one speaks of “features” – as in “BPD with narcissistic & histrionic
features”
3
Common Symptom Disorders that may
Accompany BPD
• Depression (&/or bipolar-II hypomania)
• Anxiety (“general”, social, panic, PTSD, OCD,
agoraphobia)
• Eating Disorder (anorexia, bulimia,
“bulimarexia” – with shifting between the two)
• Disorders of Craving (besides the eating disorders): substance abuse, shoplifting, hoarding,
stalking & jealousy, promiscuity, gambling)
4
Some Less Common Symptoms Disorders
in BPD Patients
Particularly in those BPD patients who have been subjected to incest (the effects of
which are apt to be worse if occurring before age ten, if penetration were involved,
and if the relative were a father/stepfather/uncle or other member of the older
generation) – a dissociative disorder may develop. Or one may see the signs of PostTraumatic Stress Disorder.
Management may be difficult in these situations. SSRI antidepressants are often
recommended for PTSD, yet in general antidepressants are not routinely useful in
BPD (though they tend to be extensively over-prescribed).
Caution is also necessary, since a proportion of BPD patients are simultan-eously
Bipolar-II or Bipolar-III (the hidden bipolars – whose tendency to manic symptoms may
be brought to the surface through use of antidepressants).
Sensitivity is needed – in knowing when to begin exploring past molestation, lest
exploration that is premature or too deep make the patient’s anxiety worse.
5
A Meyer-Lindenberg: Scientific Amer Mind, Spring 2009, p 41ff; B King-Casas: Science vol 321, 887-80, 2008
Neuroscience Looks at BPD
BPD patients have been shown via fMRI to have
abnormally small areas in parts of the limbic
system, in many cases: areas subserving
negative moods show the greatest reduction in
volume. This may mean loss of inhibitory
neurones, such that the patients have less
effective “brakes” on negative emotion. This
may contribute to impulsivity and to overly
negative reactions to stressful events.
Also: the Ant.Insula may not be giving proper
signals that indicate a problem in a relationship, leading to poor distinction as to whom one
can trust, and later – to general distrust of
others.
6
Mary Zanarini’s Comments on the Essential
Nature of BPD Psychopathology
Core feature of BPD may be intense inner pain, coupled with an awkward means by
which to express this pain. There are affective & also cognitive components.
The core features may stem from an interaction of a “hyperbolic” temperament (with a
tendency to over-react to stimuli) x “kindling” events usually of a traumatic nature,such
as sexual or physical abuse, or intense humiliation, during childhood.
Hyperbolic (overheated)
temperament
Traumatic childhood
causing shame, rage,
sorrow, terror…
The acute symptoms are often quicker to resolve,
whereas the temperament traits change slowly &
relatively little
Triggering Events:
puberty, first love affair,
humiliation by relative
BPD
7
Management Issues
The first-line treatment for BPD is psychotherapy [cf. Amer J Psychiatry report 2001]
Psychotropic medications are seen as ancillary or adjunctive. The report (relying
mainly on Paul Soloff’s research) recommended mild anxiolytics for anxiety
symptoms (avoiding benxodiazepines insofar as possible), neuroleptics in low doses
for cognitive distortions, and mood stabilizers for those with marked mood swings
(e.g., medications like lamotrigine or lithium).
Zanarini emphasizes that BPD patients (the majority of whom are women) have, as a
group, experienced more sexual abuse than have patients with other pers. disorders.
As to which thpe of psychotherapy: Though some still adhere to the belief that one
form is distinctly superior to the others, there is less and less support for this. Yet it is
important to be grounded in one specific form of therapy – that constitutes one’s
foundation as a therapist. From there one can acquire familiarity and knowledge of
some of the techniques of the other main approaches – for use when & if needed.
8
Common Personality Configurations that may
Accompany BPD
• Narcissistic
• Histrionic (akin to “Infantile”)
• Antisocial
• Depressive-Masochistic
• Avoidant
• Paranoid
• Schizotypal
• Hypomanic
9
Therapists Need to Take into Account the
Total “Profile” of Personality Traits
T
I
R
N
A
T
I
E
T
N
High
High
x
x
x
x
x
S
x
I
x
T
Y
x
Low
Na
Hi
AS
x
DM
Av
Par
Sty
Low
x
O-C
x
x
Pag Dpr Hyp other
10
Therapists Need to Take into Account the
Total “Profile” of Personality Traits
High
High
x
x
x
x
x
x
x
x
Low
Na
Hi
AS
DM
x
Av
x
Par
Sty
x
O-C
x Low
Pag Dpr Hyp other
11
Good vs Bad Prognosis,
as judged by the array of other traits
The BPD patient who showed the profile of traits in the first
diagram (red lines) was predominantly histrionic, masochistic,
avoidant, depressive, and narcissistic.
This is a much more favorable situation, prognostically, than the
profile of the second BPD patient (green lines), who was
predominantly narcissistic, antisocial, paranoid, passiveaggressive, and hypomanic. Such a patient would be less
amenable to any of the treatment approaches now in common
usage, whereas the first might do well with any of a variety of
approaches.
12
Demographic & Background Factors
UNFAVORABLE
FAVORABLE
Supportive family
Chaotic, unsupportive family
Some favorable work history
No work history
Average or better intelligence
Below average intelligence, No
talent or interests; poor in school
Fairly good academic record; talent
Minimal or no substance abuse
No incest history
Some self-mutilation & suicide gestures, few or no attempts
Middle class or better status
Heavy drug abuse; refusal of A.A.
History of incest (esp. before age
10)
Several near-lethal attempts
Poverty
In trouble with the law
13
No Two BPD Patients are Entirely Alike
Background
Factors
Other
X
Symptoms
X
Pers. Traits
Great Diversity within the BPD Domain
14
Optimal Management
Depends on the Mixture Relevant to each
Patient
CURRENTLY WIDELY USED TREATMENT METHODS
Transference Focused Psychotherapy [TFP]
Dialectic Behavior Therapy [DBT]
Cognitive-Behavioral Therapy [CBT]
Mentalization-Based Therapy [MBT]
Schema-Based Therapy [SBT]
Supportive Psychotherapy [SPT]
15
Therapeutic Approaches & their Primary
Goals
• TFP – improvement in object relations
• DBT – better emotional regulation
• CBT – reduce maladaptive cognitions
• SFT - create more adaptive schemata
• MBT – enhance reflective function
• SPT - set limits, encourage, calm
emotional storms, educate about life
16
The Situation with Typical Borderline
(BPD) Patients
CBT aims at
DBT aims at
skill building &
Sx reduction
The typical
making ideas &
BPD patient has
behaviors more
problems in all these
areas
adaptive
MBT
aims at the
SFT aims
improvement of
at modifying
core beliefs
realistic and
TFP aims at modifying
reflective
maladaptive object
functioning
relations
17
Integrated Therapy for BPD
as championed by Dr John Livesley
Therapists who work with Borderline patients have usually been trained in
one of the main treatment approaches. It is important to acquire familiarity
with several other methods – so that one can bring to the therapy a more
integrated and flexible approach. Especially in the opening phases of the
treatment, BPD patients will often be chaotic, impulsive, self-destructive in
various ways – and will require limit setting and other supportive interventions.
Many will require different forms of group therapy designed to help BPD
patients gain control over impulses to abuse substances, to regulate eating
patterns, to curb tendencies to sexual promiscuity & to unsafe sex or to shoplifting & other forms of petty theft, to taking up with strangers in bars, and to
other forms of inappropriate or reckless behaviors.
Much effort will be directed to converting the patient’s tendency to “act out”
into talking with the therapist instead of behaving self-destructively.
18
The Importance of Flexibility
as advocated by Judd & McGlashan
Work with BPD patients is not for everyone. What is needed is flexibility and creativity
within an ethical and commonsense frame. This means, among other things, careful
attention to countertransference, including the temptation to acquiesce to the
patient’s desire to “actualize” the transference. BPD patients are very prone to wanting
the therapist to BE a friend or parent or lover, rather than to talk with the therapist
about why such wishes had become so pressing and urgent.
Many an incest victim, for ex., were raised in an atmosphere where “love” was shown
through sexual molestation. BPD patients from such a background often have a hard
time understanding that it is quite unnecessary for a therapist to repeat such behavior
in order to show respect, kind regard, interest, sympathy, etc. The patient has, in effect,
to learn the language of ordinary communication of feeling via words – since she (it
will usually be a “she”) was raised only on the language of action.
19
More on Judd & McGlashan
[TH Judd & TH NcGlashan: A Developmental Model of BPD.
APPI, 2003
Re: Empathy…Empathic capacity may be part of our genetic heritage as an important
element in our equipment for survival. It requires the experience of our intentions
being understood & responded to – by significant others (the parents, for starters) in a
consistent manner. Work with BPD patients requires a better than average ability to
maintain consistent empathy, since the patient often fails in this endeavor toward self,
therapist, and other people.
The evolutionary psychiatrists, McGuire and Troisi, have underlined how BPD patients
are exceedingly hungry for attachment. Toward that end, they often become manipulative, seductive, clingy, demanding – with their therapists. Yet they are also prone to be
exploited by bosses, friends, therapists and others – from whom they so ardently (and
all too often, blindly) seek this attachment.
20
A Management Issue:
Dealing with dichotomous thinking
All clinicians who deal with BPD patients make reference to their tendency to dichotomous
(that is, all-or-none) thinking, as is often manifest in the defense of “splitting.”
They seem unable to hold opposite sets sets of feelings in consciousness – at the same
time. They instead swing between extreme positive//loving attitudes and extreme
negative//hateful attitudes. When they are in the one state, they become unaware of the
other attitudinal state (which seems to go “off-line” temporarily).
One side-effect of this pathology of thought is “paradoxical behavior.” The patient behaves
as though the other person is “all bad” at one moment; there may then be a sudden shift in
attitude, and the person is seen as “all good.”
Therapists working with this phenomenon have the task of getting the patient to move
away from these extreme positions – toward INTEGRATION, where the patient can begin to
understand the complexity of human feelings, and that they do actually hold simultaneously contrasting attitudes toward self and other. This in time permits more calm and less
chaotic, less exaggerated, and more realistic and more consistent feelings to emerge.
21
Inordinate Anger
As Judd & McGlashan emphasize, treating BPD patients requires that we can deal
adaptively with their frequent flashes of anger – often amounting to full-blown rage.
We need to withstand the outpouring of anger, without taking it personally, without
being intimidated, and without making premature//inappropriate responses.
BPD patients are notorious for visiting on us the same kinds of devaluation and
contempt that they may have experienced when still living with their original families.
It is our job to understand this and, in a humane and compassionate yet firm way,
deal with it. We try to get the patient to THINK about the anger rather than to ACT:
“OK, I can see you’re boiling over with rage right this minute! Let’s see if we can take
a step back and think about what probably triggered that anger…let’s hear what
comes to mind…”
BPD patients who have been traumatized tend often to reenact rather than to
recollect what happened to them in the past, or to recollect what incident in the hereand-now may have sparked the old traumatic memory.
22
The Importance of Motivation
Collaborative Relationship
Motivation
Kernberg has also emphasized the importance of Genuine Concern about one’s
condition – as an important element in successful treatment of BPD patients.
23
The Time Factor
Many of the currently popular therapies have been compared recently by
means of randomized control studies [RCS], involving 2 or 3 different
approaches. The studies are usually carried out for a year or two.
There is an inherent problem in such design, since patients with BPD often
require much more time in treatment - five or six years or even more.
The results of these studies tend to focus on the symptom-dimension of
BPD – since many of the symptoms (self-cutting, substance abuse…) can be
alleviated within the time-frame of the study. But helping the borderline
patient establish a harmonious relationship with a sexual partner or to
achieve social success to the point of having a good circle of friends often
takes much longer. Borderline patients who have not completed school or
college, and who have spotty work records may also require longer time
periods before they can become financially independent. Longer time in
treatment is usually necessary, and so is long-term follow-up.
24
More than One Approach is Often Necessary
Year 1
2
3
4
5
6
>6
Period of chaos
Acting out is now less
Therapy may now
Tapering of session
& impulsivity;
& therapeutic alliance
decrease to once a
frequency may be
need for limit-
is stronger; TFP or
week instead of two.
in order; focus is on
setting, support
another dynamic Rx
Need for medica-
close relations,work
& validation…
or DBT, CBT useful
tion may be less.
& dystonic traits…
25
The Patient’s Cognitive Style
Therapists need to pay attention to the patient’s inherent cognitive style.
Some BPD patients, at least at the outset, appear to have little capacity for selfreflection//introspection//putting themselves in the shoes of the other person
(mentalization). A psychodynamic type of psychotherapy will be difficult to set in
motion with such patients. They tend to forget their dreams or else not to work well
with them if they do occasionally recall one. They may respond better and more
quickly to cognitive/behavioral/schema-based approaches. Some (though not all)
will in time develop better reflective capacity, at which time a more dynamic
approach may prove fruitful.
But no one approach is good for all BPD patients.
Sometimes the degree of earlier traumatization is so overwhelming that deep reflection upon
it would (certainly in the beginning) be overwhelming also. I had occasion in December 08 in
London to hear about BPD patients – incest victims to the maximum, who had disemboweled
themselves or had cut their genitals. Such patients are likely to be too ill, too disturbed, to
deal (at first, maybe forever) with transference issues.
26
Mechanisms Intrinsic to Any Therapeutic
Modality
A therapeutic relationship that fosters support & security via
accurate empathy, non-possessive warmth, and therapist’s genuineness, as emphasized by Carl Rogers…
Technical interventions that provide new learning experiences, and
new opportunities to apply newly acquired interpersonal skills and
new occupational skills
27
Factors Related to Outcome
The specific treatment modality (such as CBT, DBT, TFP, MBT…) appears to
account for only a modest percentage (in the range of 10%) of the variance
Almost half the variance in outcome is accounted for (in the range of 40%)
by the general mechanisms embodied in any and all the approaches
The large remainder is accounted for by the qualities inherent in the
borderline patient: strength of motivation, level of perseverance; whether
the patient can form a meaningful attachment, versus being “dismissive”
in attachment style. Therapists’ ability to deal with stormy emotions, rage
outbursts, emergency situations – forms part of this portion also.
28
Self-Cutting in BPD: Response to Therapy
Likelihood of
Approximately similar success rate
in diminishing the tendency to selfdamaging acts – with TFP, MBT,
DBT
.9
Parasuicidal
Acts,such as
Wrist cutting,
Non-lethal
Suicidal
.5
gestures
.1
Year
0.25
0.5
0.75
1.0
29
Hierarchy of Treatment Goals
•
•
•
•
•
•
•
•
(as emphasized by TFP, DBT)
Attention to suicidality
Preserve therapeutic relation
Deal with life-threatening
symptoms [drug abuse, anorexia]
Deal with other symptoms [mild
depression, bulimia]
Deal with key personality traits
[jealousy, irritability]
Attend to key object relations
Work on life-goals, aspirations,
hobbies; urge patient to work or
attend school, if pertinent
• (as emphasized by Livesley)
• Phase 1: safety & support
• Phase2: containment (support,
medication if indicated)
• Phase 3: Control & Regulation
(toleration of strong affects, etc)
• Phase 4: Exploration and Change
(can be cognitive, dynamic,
interpersonal…)
• Phase 5: Integration and
Synthesis (via dynamic or
cognitive interventions)
30
Controversial Issues in the
Management of BPD
“T/A” (Therapist/Administrator) Split. Some clinicians see advantages in the therapist
confining efforts just to the psychotherapy of hospitalized BPD patients; the administrator handles other matters such as hospital-passes, medications, visitors, etc. If the
therapist is not a psychiatrist, then medications have to be managed by a psychiatrist.
Other clinicians are comfortable with the approach in which the therapist – if an MD –
handles the medications (if needed) as well. Decisions about visitors, weekend passes
etc are usually made according to the recommendations of the whole treatment team
(whether or not there is a T/A split).
Suicidality. For BPD patients who have made significant suicidal acts, hospitalization is
often necessary. The length of stay tends to be much shorter (in the US at least) than
was the case years ago. The rationale is: lengthy stays may make the patient too
dependent upon the hospital, and may interfere with re-adjustment to life on the
outside. BPD patients who are parents with small children probably should be allowed
to return home as soon as practicable. Adolescents from destructive homes may,
however, benefit from longer time away from home (in hospital or halfway house…)
31
Controversial Issues, cont’d
Handling Suicidal BPD Patients
BPD patients who call their therapists, threatening suicidal acts, pose considerable challenges
concerning what is the best tactic for confronting the threat.
DBT recommends that – faced with such phone calls – if the patient has not as yet actually
made an act of self harm, the therapist will discuss with the patient what was the problem or life
crisis that prompted the wish for self-harm and also for the call. The effort here is to help the
patient deal more adaptively with the crisis and then NOT do the self-injurious action. But if the
patient had already done the act, the therapist does not continue the call, lest the patient
achieve a counterproductive “secondary gain” by first making the act and then begging for
sympathy.
TFP in similar situations will often recommend that the patient go to the nearest hospital
emergency unit and get the necessary care.
Both these approaches have merit, and will be useful in many cases. But there will always be
exceptions. Not all suicidal patients can be trusted to go on their own to a hospital. And if a
patient called the DBT therapist about a very serious act, a more extended conversation may be
necessary (to urge hospitalization or to prevent the situation from becoming more lifethreatening). Clinical judgment is always needed.
32
Peculiarities in the Treatment Course & in
the Life Course of BPD Patients
BPD patients will often quit treatment prematurely with one therapist, and then
seek another. The drop-out rate is thus quite high (~ 40%), which is discouraging. But
eventually the patient will find another therapist with whom he or she will feel more
comfortable, and may then make rapid improvements [cf. Dr Heller’s Pt].
This means that the eventual success rate tends to be better than what we would
have forecast, if we only paid attention to the high drop-out rate.
In long-term (10 to 25 year) follow-ups of BPD patients, about 2/3 of the patients
achieve a Global Assessment Score in the mid-60 range. Many will have stopped
making suicide gestures and self-mutilations, will have (once past age 30) found a
good friend or a sexual partner, and will not longer satisfy DSM criteria for BPD.
Depending on the age at which the patient was first treated, the suicide rate,
nevertheless, will be substantial: 3 to 9% (depending on the mix of positive and
negative factors).
33
Summary Comment
The typical BPD patient has problems with Emotional Regulation (which are
addressed with special attention in DBT), in Object-Relations (addressed with special
emphasis in TFP), and shows abnormalities in cognition (a tendency to black&white
thinking, paranoid reactions, dissociation, “past-life” experiences…) (addressed in
CBT), as well as maladaptive inner scripts or “schemata” (addressed in Schema
Focused Therapy, or in CBT), and deficits in reflective function (addressed in MBT, TFP)
besides which there are usually frequent life crises (especially at the beginning) that
will require elements of limit setting, psycho-education, 12-step programs, validation,
skills-training, sympathy, encouragement – such as are offered in Supportive Psychotherapy & in DBT.
34
Summary, cont’d
Usually – collaborative and cooperative exchanges between therapist & patient are the
primary healing elements.
The therapist’s task is, while still adhering mainly to the approach adopted in the
therapist’s original training, is to remain flexible and adaptive enough to select
interventions from some of the other approaches that might prove most useful at any
given moment in the course of the treatment. It will at times be prudent to refer the
patient to specialists in one or another of the alternative approaches, if more extensive
application of those approaches proves necessary. Where substance abuse is a major
factor, enrollment in AA or Narcotics Anon etc will be essential; other forms of group
therapy may be indicated for gamblers, eating disorder patients, and the like.
All this makes for an integrated therapy.
No single approach stands out as superior across the board to all the others. All
include effective interventions (many of which will be quite similar, albeit expressed in
a different vocabulary).
35